In 1970 the rich world promised a dramatic increase in aid to developing countries: they would “endeavour to provide” 1% of their national income to poor countries by 1975 at the latest.

In the same year the US announced that it was withdrawing 40,000 troops from Vietnam, and the European Community, then a club of six western European countries, opened membership talks with Denmark, Ireland, Norway and the UK.

Almost 40 years later, the US is agonising over another war, the EU27 are split over the next phase of enlargement, and developing countries are waiting for the rich world to fulfil a 2005 pledge to provide 0.7% of their national income in aid.

Lack of money is part of the reason that developing countries have struggled to develop effective health systems. Today, 2.4 billion people have no access to basic healthcare facilities.

But money is not the whole story. War, disease and corruption have all played a part, as has the ‘brain drain’ of healthcare workers to rich countries, leaving poor and middle-income countries short of 4.25 million professionals.

Stretched services

The poorest countries face a mismatch between needs and resources. Sub-Saharan Africa has 11% of the world’s population but a quarter of the disease burden, yet accounts for less than 1% of health spending. Rural areas are particularly stretched: some governments allocate 60% of their health budget to urban hospitals serving just 10% of the population, according to Action for Global Health, a campaign group.

Charges deter many from seeking treatment. When Rwanda introduced charges in the 1990s, take-up of services halved. Conversely, when charges were dropped in Uganda recently, attendance at rural health services increased by 84%.

A recent report by Oxfam, Médecins Sans Frontières and 45 other development charities and trade unions, estimated that 100 million people are pushed into poverty by healthcare charges.

Stopping the ‘brain drain’

Weak, under-funded services are why the Millennium Development Goals on health are in jeopardy. Margaret Chan, the World Health Organization’s director-general, pinpointed the problem in 2007.

“We have a multiplicity of health initiatives focused on delivering outcomes. The ability to deliver the outcomes...requires a functioning health system. Yet strengthening health systems is not the core purpose of these initiatives,” she said.

The EU institutions and the member states have pledged to increase development aid and to improve the coherence of its policies, for instance to stem the ‘brain drain’.

But the EU’s efforts on healthcare workers face criticism (see Page 24), while finance lags. Countries should be spending around 0.1% of national income on health (as part of a bigger pledge to spend 0.7% of national income on overseas development aid).

But rich countries are falling short: in 2007, neither France, Germany, Italy, Spain nor the UK met the 0.1% goal, according to analysis by Action for Global Health.

At a United Nations meeting in September, rich countries promised to spend $5 billion (€3.3bn) to improve access to healthcare for ten million people in Nepal, Malawi, Ghana, Liberia, Burundi and Sierra Leona. Funds will come from the travel industry and the Austrian, Dutch, Norwegian and UK governments.

But needs far exceed the supply of money for healthcare. The WHO estimates that health budgets in 57 poor and middle-income countries will need to increase by at least $10 (€6.5) per person per year by 2025 to pay salaries, not including buildings, technology and medicines.

Whether countries will deliver on their overseas aid promises looks doubtful. A glance back over the past 40 years does not give much ground for optimism.